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Optimisé Pour L'impression 20th anniversary issue Alternative and complementary approaches in psychiatry: beliefs versus evidence Pierre Schulz, MD; Vincent Hede, MD Introduction he power of human imagination has led our ancestorsT to consider the influence of celestial bodies, spirits, and gods on the horror of diseases and death. Over millennia, priests, shamans, sacred men, and medicine men helped their peers by predicting their While the legitimacy of medical treatments is more and fate and cure on the basis of various rituals, such as more questioned, one sees a paradoxical increase in examining animal intestines or ingesting diverse com- nonconventional approaches, notably so in psychiatry. pounds. The Jesuit Athanasius Kircher (1602-1680) Over time, approaches that were considered valuable wrote of interactions between planets, plants, and by the scientific community were found to be ineffi- animals, and he considered God as the central mag- cacious, while other approaches, labelled as alterna- net of all things. The physician Franz Mesmer (1734- tive or complementary, were finally discovered to be 1815) extended Kircher’s idea into application of the useful in a few indications. From this observation, we vital principle as a therapy for psychiatric symptoms propose to classify therapies as orthodox (scientifically for which there was then no therapy (Figure 1). In the validated) or heterodox (scientifically not validated). United States, members of the Fox family declared by To illustrate these two categories, we discuss the place, 1888 that their mediumnity was in fact a hoax, which the role, the interest, and also the potential risks of did not stop the appeal of exchanging messages with nonconventional approaches in the present practice of the dead; only later in the 20th century did spiritism fall psychiatry. into some disrepute. © 2018, AICH – Servier Group Dialogues Clin Neurosci. 2018;20:207-214. Frontiers between recognized treatments and char- latanism have long been a theme of discussion, and Keywords: alternative and complementary medicine; evidence-based medicine; Address for correspondence: Dr Pierre Schulz, 4 boulevard de la Tour heterodox; orthodox; psychiatry 1205, Geneva, Switzerland Author affiliations: Former Head, Unit of Clinical Psychopharmacology, Department of Mental Health and Psychiatry, Geneva University Hospi- tals, Geneva, Switzerland (Pierre Schulz); Mood Disorders Unit, Depart- ment of Mental Health and Psychiatry, Geneva University Hospitals, Ge- neva, Switzerland (Vincent Hede) Copyright © 2018 AICH – Servier Group. All rights reserved 207 www.dialogues-cns.org 20th anniversary issue Louis of Jaucourt (1704-1779) wrote about this in the to our proposed qualifiers, CAMs can be orthodox in Diderot and d’Alembert Encyclopedia: given indications: biofeedback, neurofeedback, hypno- The desire to live is a passion so natural and so strong it sis, virtual reality techniques, mindfulness relaxation, is not surprising that those who in health have little or no omega 3 fatty acids, etc, while previously conventional faith in the skillfulness of an empiric with secrets, appeal approaches have been given up (frontal lobotomy, insu- nonetheless to this false physician in grave and serious ill- lin coma, meprobamate), and many nowadays off-label nesses, the same as those who are drowning cling to the prescriptions can be seen as heterodox. smallest branch. They persuade themselves of having re- ceived aid, each time that skilled men did not have the Clinical illustration 1. This 45 year-old patient is in effrontery to promise them a certainty. ambulatory care because of severe depression. He had Nowadays, complementary and alternative medicines been doing clerical work for 15 years but lost this job (CAMs) are presented as safe, effective and affordable because of conflicts with his boss. Psychotherapy, anti- treatments, also for mental health problems. We discuss depressants, and augmentation treatment were without this category of approaches in mental care, excluding benefit. He consulted another medical doctor who or- from this paper the role of traditional treatments in dered tests measuring neurotransmitters and their me- countries with little medical staff, where other tradi- tabolites, amino acids, and immune globulins, and pre- tional healers take care of the burden of disorders. scribed unusual treatment such as micronutrition and hormones. This gave the patient a feeling of being well Definition taken care of, although his depression did not improve. CAMs are diagnostic techniques and treatment prac- tices outside mainstream and standard health care. It is said that complementary approaches are added to stan- dard health care, while alternative ones are substitutes for it, a somewhat spurious non-operational nuance, be- cause adding an alternative approach to a conventional one would make it complementary by definition. Inte- grative medicine is the combination of standard health care with CAMs, either simultaneously or successively. Some CAMs can be a priori labeled as charlatanism, ie, as useless approaches sold by charismatic healers to vulnerable customers. We propose two qualifiers related to CAMs as well as to standard health care. We label as orthodox (from the Greek ortho meaning right or straight path and doxa meaning belief) those techniques that have adequately, ie, scientifically and rationally, been demonstrated to be efficacious and useful. The history of discoveries of orthodox methods starts with the first schools of medicine in the early Mediterranean world, even ear- Figure 1. Franz Mesmer’s tub according to a 1784 French engraving lier elsewhere. We label heterodox those techniques The tub (baquet) contained immersed bottles with magnetized wa- ter and iron fillings. Iron rods coming out of the tub were directed that have been demonstrated as useless for diagnosis towards body parts and harmonica music was played while the pa- (iridology, astrology, etc) or as equivalent to placebo for tients held hands. Mesmer, who had fled from Vienna to Paris, was treatment (homeopathy, prayer for others, etc) or for considered a genius by some and a charlatan by others. Eight mem- which there is no reason to hope for efficacy over that bers from the Académie de Médicine and the Académie des Sciences demonstrated that the tingling, trembling, tears, and even convul- of placebo (protection through crystals, auriculothera- sions observed in persons who knew they were being magnetized py, aura therapy, Ho’oponopono, etc). Some heterodox were absent when subjects were magnetized while being unaware approaches date back thousands of years. According of it. 208 Psychiatry alternative treatments - Schulz and Hede Dialogues in Clinical Neuroscience - Vol 20 . No. 3 . 2018 Practitioners of heterodox approaches have at- do not spend enough time with patients, conventional tempted to have their techniques accepted as orthodox, treatment is not well reimbursed, wellness is a higher for example orgone machines by Wilhelm Reich, primal goal than the mere decrease in symptoms, viewing a therapy by Arthur Janov, orthomolecular psychiatry by person as a whole leads to a more human society, mod- Carl Pfeiffer. Treatment of depression under halluci- ern science bridges with ancient wisdom, the normal nogens, psychoanalysis, narco-analysis, and psychosur- state of Mother Nature is health, CAMs and other het- gery shifted from being heterodox to orthodox, only erodox approaches generate hope. People are induced to be later considered again as heterodox or possibly into using CAMs by the fact that science education is so. Some approaches are difficult to label as either or- neglected, by the existence of national and internation- thodox or heterodox because of lack of clinical studies al conferences on CAMs, and by the lack of state regu- or because of the unusual aspect of the method: pet- lations and recommendations. assisted therapy, visual and acoustic brain stimulation Suggestion is another reason for choosing CAMs. It machines, fecal microbiote transplant in psychiatry, etc. leads to reassurance and empowerment of the client: the therapy will work because the CAM practitioner says Multiplicity of complementary and so, and because he or she indicates that it restores har- alternative medicines mony and balance within bodily and mental energies. This is often felt as psychologically more comfortable CAM techniques are many and can be classified as than a medicine driven by technology, even if centered mainly biologically based (phytotherapy, diets, mas- on the patient, with its probabilistic predictions based sage) or addressing the mind/body relations (relaxation, on the complexity of clinical status, familial medical his- techniques of energies balancing, therapeutic action at tory and paraclinical testing (epigenome, metabolome, a distance). Clients searching for relief from psycho- proteome, genome, etc) and, in psychiatry, neuropsy- logical suffering can use, to quote a partial alphabetical chological testing and neuroimaging. Even this knowl- list of CAMS, acupressure, acupuncture, animal-based edge does not suffice to build certainty and uncertainty therapy, anthroposophy, atlas repositioning, astrology, remains an arduous concept for patients and doctors to aura therapy, auriculotherapy, Ayurveda, bracelets and acknowledge.1 With CAMs, empowerment arises from medals, Coué method, cryogenic whole body therapy the ease of understanding simple causes and mecha- at minus 100°C, crystals and minerals, DNA healing nisms
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